United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for February 14, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/13/2012 - 02/14/2012

** EVENT NUMBERS **


47646 47647 47648 47650

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Agreement State Event Number: 47646
Rep Org: NJ RAD PROT AND REL PREVENTION PGM
Licensee: ROBERT WOOD JOHNSON UNIV HOSPITAL
Region: 1
City: NEW BRUNSWICK State: NJ
County:
License #: 450729
Agreement: Y
Docket:
NRC Notified By: WILLIAM CSASZAR
HQ OPS Officer: CHARLES TEAL
Notification Date: 02/08/2012
Notification Time: 12:18 [ET]
Event Date: 02/07/2012
Event Time: 19:00 [EST]
Last Update Date: 02/08/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ART BURRITT (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - PATIENT RECEIVED DOSE LESS THAN INTENDED

The following was received from the state of New Jersey via email:

"A patient was treated with a Varian VariSourceTM HDR unit on February 7, 2012. The prescription dose was 200 cGy per fraction for 8 fractions. The first two fractions were delivered to the patient with a fractional dose of 25 cGy instead of the prescribed fractional dose of 200 cGy before the discovery of the event around 7 p.m. on February 7, 2012. The initial treatment plan was designed for a single fractional dose of 200 cGy and was approved on screen by the physician. The plan was later modified to 8 fractions with a fractional dose of 200 cGy before the delivery of the first fraction. This modification was however done incorrectly and the isodose line of 200 cGy, instead of 1600 cGy, was planned to cover the target volume. [Isodose means a radiation dose of equal intensity to more than one body area.] Two fractions of treatment (out of a planned 8) were delivered on 2/7/2012 before discovery of the event, resulting in a dose of 25 cGy per fraction (instead of 200 cGy) prescribed to the target volume."


A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

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Agreement State Event Number: 47647
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: NATIONAL ANALYTICAL INSTRUMENTS
Region: 4
City: SAN RAFAEL State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: CHARLES TEAL
Notification Date: 02/08/2012
Notification Time: 13:45 [ET]
Event Date: 01/24/2012
Event Time: [PST]
Last Update Date: 02/08/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4DO)
PAUL MICHALAK (FSME)

Event Text

AGREEMENT STATE REPORT - CONTAMINATED VARIAN DETECTOR

The following was received from the State of California via email:

"On January 24, 2012, RHB was informed by the owner of National Analytical Instruments [...] that he had purchased a Varian UV-VIS detector from Golndustry Dovebid back in 06/11/2008 and he subsequently learned this device was contaminated with C-14.

"The purchase invoice ID is # 2169450, and the following equipment was indicated on the invoice: Varian ProStar 320, s/n 1550, Lot # 143568. The equipment has a Pfizer's asset number 16468. According to [the owner], the equipment came from Pfizer in Ann Arbor, Michigan, and that this laboratory has been owned by the University of Michigan since 2007.

"On January 24, 2012, the RHB inspector confirmed contamination of the Varian UV-VIS detector. A Thermo Scientific, RadEye B20-ER, s/n 0242 GM, survey meter was used to check for contamination, and contamination was observed with the maximum reading of 25 CPS. On January 26, 2012, in the presence of RHB inspector, the Pfizer San Francisco RSO took surveys, and also confirmed contamination of the Varian UV-VIS detector. The Pfizer RSO also took possession of the contaminated equipment."

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Agreement State Event Number: 47648
Rep Org: MINNESOTA DEPARTMENT OF HEALTH
Licensee: ABBOTT NORTHWESTERN HOSPITAL
Region: 3
City: MINNEAPOLIS State: MN
County:
License #: 1007-211-27
Agreement: Y
Docket:
NRC Notified By: TERESA PURRINGTON
HQ OPS Officer: CHARLES TEAL
Notification Date: 02/08/2012
Notification Time: 16:00 [ET]
Event Date: 02/03/2012
Event Time: [CST]
Last Update Date: 02/08/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN GIESSNER (R3DO)
PAUL MICHALAK (FSME)

Event Text

AGREEMENT STATE REPORT - Y-90 THERASPHERE DOSAGE TO UNINTENDED AREAS

The following was received from the State of Minnesota via email:

"On February 3, 2012, Minnesota Department of Health Radioactive Materials unit received notice that a licensee had a medical event during a Y-90 SIRS spheres procedure. After infusion of radioactive Y-90, in the form of SIRS spheres for treatment of the liver, it was discovered, by follow-up radionuclide scanning, that some of the material was not in the liver as intended. Material appeared in vessels involving the spleen and digestive track instead. The amount has not been determined at this time, but it is possible that this may cause unintended, permanent, functional damage. The interventional radiologist involved with the treatment has ensured us that the patient will be notified along with the referring physician today. It is likely that some form of medical intervention will be taken.

"On February 6, 2012, the Radioactive Material supervisor and inspector met with the licensee to discuss the medical event. The Y-90 SIRS spheres procedure went accordingly to plan; it was discovered on the follow-up SPECT imaging that an estimated 10%-15% of the material was in the spleen, gastric fundus, and duodenum. The patient and ordering physician had been notified. The intended area for the material was the liver with an activity of 50 GBq. The three unattended areas that were discovered with material were estimated to receive a dose of 0. The Medical Physicist gave us the best preliminary dose estimates based on CT images obtained the day after the procedure at which the stomach and duodenum were different in shape. Early dose estimates for each region (spleen, gastric fundus, and duodenum) estimates approximately 30 Gy for each area.

"The Minnesota Department of Health Radioactive Materials unit will continue communication and obtain the final estimation for dose estimates."

A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

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Agreement State Event Number: 47650
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: MULTI-CINEMA INC
Region: 4
City: OKLAHOMA CITY State: OK
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JENNIFER MCALLISTER
HQ OPS Officer: CHARLES TEAL
Notification Date: 02/08/2012
Notification Time: 15:51 [ET]
Event Date: 01/31/2012
Event Time: [CST]
Last Update Date: 02/08/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4DO)
PAUL MICHALAK (FSME)

Event Text

AGREEMENT STATE REPORT - MISSING TRITIUM EXIT SIGN

The following was received from the State of Oklahoma via email:

"On January 31, 2012, Oklahoma Department of Environmental Quality (ODEQ) received email notification from America Multi-Cinema, Inc. (AMC) that they had lost one (1) tritium (H-3) radioluminescent exit sign. The amount of H-3 is unknown. AMC has filed a report for the Oklahoma City Police Department. The case number is 12-001181. According to AMC, the missing exit sign was discovered before a site survey had been performed, so AMC could not provide the manufacturer or serial number of the stolen unit. At this time, no further information is available."

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012